What is your name?
Branch number (if applicable)
Reference number from NRLS report (obtained when completing the NRLS report)
Date of incident*
Time of incident*
Describe what happened* (Give as many details as necessary to enable others to understand the circumstances and be able to learn from the event. State facts only and not opinions.)
Degree of harm to the patient (severity)*
Did any actions minimise the impact of the incident on the patient?* (Please describe)
If the patient took/used the medicine/medical device, what symptoms did they experience?*
Send me a copy of my responses.
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